PERIANAL SURGICAL

CONDITIONS
Fitsum Argaw
ANATOMY
• Rectum is continuous with the sigmoid colon at the level
of S3 vertebra
• Is continuous inferiorly with the anal canal
• Rectum is approximately 12 to 15 cm in length
• Anal canal measures 2 to 4 cm in length and is generally
longer in men than in women
• Dentate or pectinate line marks the transition point
between columnar rectal mucosa and squamous anoderm
•Submucosal plexus deep to the columns of Morgagni forms the hemorrhoidal plexus and
drains into all three veins
ANATOMY
• Lymphatic drainage of the rectum parallels the vascular
supply
• Lymphatic channels in the upper and middle rectum
drain superiorly into the inferior mesenteric lymph nodes
• Lymphatic channels in the lower rectum drain both
superiorly into the inferior mesenteric lymph nodes and
laterally into the internal iliac lymph nodes
HEMORROIDS
• Cushions are aggregations of:
– Blood vessels (arterioles, venules, and arteriolar-venular
communications)
– Smooth muscle
– Elastic connective tissue in the submucosa
• Normally reside in the
– Left lateral
– Right posterolateral
– Right anterolateral anal canal

• Hemorrhoids are likely the result of

a sliding downward of anal cushions
• Provide tissue to close the anal canal
during rest
CLASSIFICATION
• Internal hemorrhoids
– Reside above the dentate line
– Covered by transitional and columnar epithelium
• External hemorrhoids
– Consist of the dilated vascular plexus located below the dentate line
– Are covered by squamous epithelium
• Mixed hemorrhoids
– Composed of elements of both internal and external hemorrhoids
 Anal skin tags
– Discrete folds of skin located at the anal verge
– May be the result of thrombosed external hemorrhoids, or more
rarely may be associated with inflammatory bowel disease
INTERNAL HEMORRHOIDS
 First-degree – cause painless bleeding with defecation
 Second-degree – protrude through the anal canal at the time of
defecation, but spontaneously reduce
 Third-degree – protrude and bleed with defecation, but must be
manually reduced
 Fourth-degree – permanently fixed below the dentate line and
cannot be manually reduced
ETIOLOGIES
• Hereditary
– Venous wall weakness
– Increase in blood flow
• Factors which increase the straining habit or other mechanisms
– Chronic constipation
– BOO
– Pregnancy
– Rectal Ca
– Chronic diarrhea
• Idiopathic
CLINICAL MANIFESTATIONS
• Bleeding
– Commonest symptom of internal hemmorhoid
– Painless, bright red, not mixed with stool, initially or end of defication
– Streak to massive (severe)
– Intermittent, for months or years
• Pain
– Not in internal hemorrhoid unless thrombosed
– In external hemorrhoid
• Prolapse → varying degree
• Pruritis – because of discharge
• Discharge
• Protrusion during straining
• DRE – mass, blood
CLINICAL MANIFESTATIONS
• External hemorrhoids (usually thrombosed)
– Pain – presenting symptom
– Tender, tense, single or multiple mass at the anal verge
– Skin tags
• Investigation
– Proctoscopic examination
• Mass, lesion in first degree hemorrhoid
• Associated fissures
– Colonoscopy should be performed in high-risk patients to
exclude other sources of bleeding
• Carcinoma
• Proctitis
COMPLICATIONS
 Hemorrhage – shock, anemia
 Strangulation

 Thrombosis

 Fissure in ano

 Ulceration

 Suppuration – abscess, septic emboli, fistula

TREATMENT
 Treatment of predisposing factors
 Medical Therapy
 Regulation of diet
 Avoidance of prolonged straining at the time of defecation
 Increasing fiber content of the diet
 Improved hygiene
 Annusole cream and tablet
TREATMENT
• Surgical therapy
– If bleeding and protrusion persist
– Elastic (Rubber Band)ligation of the friable redundant
hemorrhoidal tissue
• Satisfactory for first-, second- and third-degree hemorrhoids
• ligatures must be placed at least 1–2 cm above the dentate line to
avoid extreme discomfort
– Sclerotherapy
• Effective technique for treatment of first-, second-, and some third-
degree hemorrhoids
– Operative Hemorrhoidectomy
• Open or closed hemorrhoidectomy
• 3rd- ,4th-, failed 1st and 2nd degree hemorrhoids
ANORECTAL ABSCESS
 An invasion of pararectal tissues by microorganisms
 Pathogens
 Are usually mixed infection (E.coli, proteus, staph, strept, bacteroids)
 60% are due to pure E.coli

 Infections arise in the anal glands( which is in intersphincteric) that

communicate with the anal crypts (cryptoglandular disease)
 As abscess enlarges, it escapes the confines of the intersphincteric
plane and spreads in one of several possible directions
 The acute phase of the infection causes an anorectal abscess
 The chronic stage is recognized as an anal fistula
CLASSIFICATION
Based on location
 Perianal abscess
 Beneath anal skin and mucosa of anal canal
 60% of anorectal abscess

 Ischiorectal abscess
 Lateral and posterior to the anus and is bounded medially by the external
sphincter
 May percolate to contra lateral side forming horseshoe abscess
 30% of anorectal abscess

 Retrorectal (deep postanal)

 Submucosal
 Immediately above the anal verge
 Supralavator
 The most common of all anorectal abscesses is a perianal
abscess
 Presents as a tender, erythematous bulge at the anal
verge
 An ischiorectal abscess is formed when a growing
intersphincteric abscess penetrates the skeletal muscle of
the external sphincter below the level of the puborectalis
and expands into the fat of the ischiorectal fossa
 Sources
 Anal gland (crypt) infection
 Commonest
 Perianal skin & upper thigh infection
 Infected hematoma, hematogenous
 Rectal wall penetration
CLINICAL MANIFESTATION
 Pain
 More common in superficial abscess
 Less in deep abscess

 Systemic manifestations, fever, tachycardia,

 More common in deep abscess
 Tender indurated swelling
 DRE – flactuating tender mass
COMPLICATIONS
 Dissiminated infection
 Necrotizing fascitis

 Fistula in ano
 In 60% of patients
TREATMENT
 Antipain, anti inflammatory
 Antibiotics – broad spectrum

 Surgical drainage

 Sitz bath
FISTULA IN ANO
 Must have two epithelial openings connected by a
hollow tract, as opposed to sinus (only one opening with
blind end)

 Usually from cryptitis either due to spontaneous rupture

or inadequate surgical drainage of Perianal abscess
CLASSIFICATION
 Subcutaneous(Extrasphinicteric) : extend from an internal
opening in the bowel proximal to the anus, encompass the
entire sphincter apparatus, and open onto the skin overlying
the buttock
 Intersphinicteric: travel along the intersphincteric plane to the
perianal skin
 Transsphincteric(Submucousal): fistulas encompass a portion
of the internal and external sphincter, and terminate on the
skin overlying the buttock
 Supralavator (Suprasphinicteric): fistulas encompass the entire
sphincter apparatus

Or
 High
 Low
CLINICAL MANIFESTATION
 Intermittent or constant serosangeneous fluid discharge
 Usually for years
 Pink or red elevation of granulation tissue within 3cms
from anal verge (external opening)
 Internal opening almost always single

 External opening can be one or more

CLINICAL MANIFESTATION
 If >1 external opening or if it is >3cms away from the
anal verge, think of granulation lesions like IB disease or
malignancies – do biopsy
 Goodsall’s rule
 External opening anterior to mid—of anal verge, internal
opening is direct
 External opening posterior to midline of anal verge, has
curved course and most open to posterior midlines
Goodsall's rule
DIAGNOSIS
 Proctoscope –internal opening
 Hydrogen peroxide injection can help to identify the internal
opening with necked eye
 Radiology – fistulogram
 Probing – in the OR

 Dye injection
TREATMENT
 Low fistula – fistulectomy
 High fistula – seton application with stage operation
ANAL FISSURE
 Elongated ulcer in the long axis of lower anal canal
 90% on mid post. Line

 More common in females

ETIOLOGIES
 Can be primary or secondary depending on:
 Anatomic site
 Ischemia

 Uncorrect surgery
 IBD

 STDs

 Constipation

 Homorrhoids
 Can be:
 Acute – deep tear with
 Inflammation
 Induration
 Splitting of sphincter
 Chronic
 Inflammed indurated margin
 Inflammation → abscess → fistula
 Once the tear occurs, it begins a cycle leading to
repeated injury

 The exposed internal sphincter muscle beneath the tear

goes into spasm

 In addition to causing severe pain, the spasm pulls the

edges of the fissure apart, which impairs healing of the
wound
 ANAL FISSURE

Tear

Edges pulled apart Pain

 Bd. supply

Spasm

This cycle leads to chronic anal fissure

CLINICAL FEATURES
 Any age can be involved
 Pain
 Sharp, agonizing, during defication for minutes following
defication
 Periods of remission – days/weeks

 Bleeding
 Bright red, slight streaks
 Dischargees
CLINICAL FEATURES
 Skin tags
 Traids
 Fissure
 Tags

 Hypertrophied Perianal tissue

 Tight, closed anus

 DRE – pain ful
TREATMENT
 Objective – relaxation of sphinicter
 Non-surgical (chemical)
 Muscle relaxant
 Laxatives, bulk forming agents

 Operative – chronic anal fissure

 Lateral anal sphinicterotomy
 Dorsal fissurectomy with sphinicterotomy
RECTAL PROLAPSE
 Circumferencial full thickness protrusion of the
rectum through the anus
 Starts at the lower rectum

 F:M: 6:1

 Increases with age

 High in mentally retarded patients

RECTAL PROLAPSE
Anatomic Abnormalities
 Deep rectovaginal or rectovaginal pautch

 Lax pelvic floor

 Long mesorectum

 Redundant rectosigmoid

 Atonic spincter
RECTAL PROLAPSE
Symptoms
 Tenesmus

 A sense of incomplete evacuation

 Mucous discharge

 Incontinence, diarrhea, constipation

 Fecal & urinary incontinence

RECTAL PROLAPSE
Treatment of rectal prolapse in children
 is a self-limiting disease

 responds to conservative measures

 Correctionof bowel habit
 Small doses of laxatives
 Submucosal injection of phenol or alcohol
RECTAL PROLAPSE
Treatment
AIM: - removal of intususception & prevention of
recurrence
 Colonoscopy/ Barium enema
 Anal manometry/Electromyography
 Surgery
 >100 procedures
 Abdominal or perineal operations
RECTAL PROLAPSE
Abdominal operations
 Lower recurrence rate

 High morbidity

Principle
 To reduce & hold the rectum in its proper position
(rectopexy)
 To reduce redundant colon by anterior resection
 RECTAL PROLAPSE
Anterior resection of the rectum Rectopexy
 Mortality: 0.7%  Technically easy

 Recurrence: 8.9%  Fewer complications

Recto sigmoid resection &

Rectopexy
 Preferred operation

 Recurrence: 6 – 9%
RECTAL PROLAPSE
Prolapsed segment longer than 3 to 4cm

Transperineal rectal amputation of the
Altimier type is used.
RECTAL PROLAPSE
Complications of rectal prolapse
 Ulceration

 Strangulation

 Rupture of prolapsed rectum

 Incontinence
Thank you !